Imaging of the Heart Todd Tessendorf MD FACC Outline Imaging Modalities for Structural Heart Disease ECHO, MRI Imaging Modalities for Ischemic Heart Disease SPECT, PET, CCTA Show lots of pretty pictures 1
Structural Heart Disease Echo What information does Echocardiography and Doppler provide? Size of the chambers Systolic and Diastolic function Valve Function Volume status Other Uses: fluid in the pericardium, congenital heart diseases, blood clots or tumors 2
TEE TEE provides superior image quality, particularly for posterior cardiac structures that are nearer to the esophagus and often less well visualized on TTE 3
Indications Assessment of prosthetic valves; infective endocarditis ; native valve disease Assessment of a suspected cardioembolic event; Assessment of cardiac tumors ; Assessment of atrial septal abnormalities ; Indications Assessment of aortic dissection; Evaluation of CHD; CAD ;pericardial disease Evaluation of critically ill patients Intraoperative monitoring Monitoring during interventional procedures Nondiagnostic TTE 4
3D echo More accurate and more reproducible left ventricular (LV) volume and ejection fraction (EF) measurements compared with 2D echocardiography New "surgical" views of cardiac valves, adjacent structures, and intracardiac masses Guidance of interventional procedures in structural heart disease Direct evaluation of the size and morphology of the vena contracta along with volumetric quantification of regurgitant valve lesions, shunts, and cardiac output Appropriate use criteria AUC publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography MRI 3D capabilities and a high spatial resolution Proven to be an invaluable tool in diagnosing complex cardiomyopthies. 5
Indications for MRI Quantifying left and right ventricular function Cardiomyopathy Heart failure Arrythmogenic right ventircular dysplasia (ARVD) Pulmonary hypertension Defining cardiac anatomy Constrictive pericarditis Cardiac neoplasm or thrombus Congenital heart disease Demonstrating the presence of a patent foramen ovale (PFO) 6
Quantifying blood flow Valvular disease (e.g. aortic regurgitation, mitral regurgitation, aortic stenosis, etc.) Shunts: ASD, VSD, PAPVR, and PDA Assessing myocardial scar / viability Identifying hibernating myocardium before revascularization Differentiating cardiomyopathy from old myocarditis Coronary Artery MRA For anomalous coronary arteries 7
Special consideration should be made for patients: That are poor echo candidates (e.g. bad echo windows) That are poor nuclear candidates (e.g. obesity, large breasts, small size / women). Where quantification is important Who want to avoid a more invasive test (e.g. TEE, cardiac catheterization) Who want one comprehensive test rather than multiple tests Contraindications for MRI Central nervous system aneurysm clips Implanted neural stimulator Implanted cardiac pacemaker or defibrillator Cochlear implant Ocular foreign body (e.g., metal shavings) Other implanted medical devices (e.g., drug infusion ports) Insulin pump Metal shrapnel or bullet Pregnant women (patients who are uncertain whether or not they are pregnant will be required to have a screening test) T1 WEIGHTED T2 WEIGHTED 8
Myocarditis Myocarditis: Delayed enhanced imaging demonstrate enhancement in the mid-myocardium often in a patchy pattern Nonvascular distribution Evaluation of Ischemic Heart disease Imaging SPECT vs. PET CCTA Myocardial Perfusion Imaging Indications SPECT Detects presence/location/extent of myocardial ischemia in patients with R/O ACS. Risk stratification after ACS. Identify fixed defects, evaluate EF and viability. CP with abnormal EKG s. Equivocal ETT. Inability to exercise (pharmacological stress). 9
Myocardial Perfusion Imaging Exercise SPECT Strengths SPECT Myocardial Perfusion Imaging Extensively validated, useful for cost-effective risk stratification & patient management. Widely available outpatient settings. Standardized protocols. Excellent procedural and clinical utilization guidelines published by professional medical societies. 27 accepted clinical indications. Why PET Perfusion? Obesity and poor quality studies, SPECT. Dosing Attenuation correction Image clarity. Improved diagnostic accuracy, lower false positive. Identification of multivessel ischemia. Rapid acquisition: impaired patients. Lower radiation burden. 10
SPECT vs PET Perfusion SPECT Energy: 78-140 KeV Attenuation correction: sometimes Stress: exercise, pharmacologic Protocol, start to finish: 2 2/12 hours Ventricular function: post-stress, rest PET 511 KeV Attenuation correction: always Stress: pharmacologic, exercise in future (F-18) Protocol, start to finish:30 45 minutes Ventricular function: stress, rest Radiation Exposure (msv) PET vs SPECT 11
Perfusion PET Advantages High spatial and temporal resolution. Excellent sensitivity. Accurate depth-independent attenuation correction. High contrast resolution. Quantitative imaging capabilities. AUC ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease MEDICARE S APPROPRIATE USE CRITERIA PROGRAM Program established by Congress in 2014. Requires adherence to AUC for advanced imaging services provided by professionals in the office, hospital outpatient department and ambulatory surgery center. Effective Jan. 1, 2020, prior authorization will apply to ordering professionals who are identified as outliers in AUC adherence Effective date (January 2017) delayed. Could be implemented as early as January 2018 CMS is currently in the process of creating regulations, through the process of rule making, that will govern the program 12
CCTA Coronary CT Angiogram CCTA Nonivasive CT Uses Iodinated contrast Evaluation for CAD Pros for CCTA High diagnostic accuracy Low radiation exposure Efficient Non-cardiac findings/ subclinical disease 13
Cons against CCTA Radiation Patient size IV contast Intervention Reimbursement Coronary calcium Intermediate lesions Fractional Flow Reserve- CT Nonivasive way of measuring blood flow through the heart Helps guide intervention 14
1-Year Outcomes of FFR CT -Guided Care in Patients With Suspected Coronary Disease The PLATFORM Study In patients with stable chest pain and planned invasive coronary angiography, care guided by CTA and selective FFR CT was associated with equivalent clinical outcomes and QOL, and lower costs, compared with usual care over 1-year follow-up. Pamela S. Douglas et al. JACC 2016;68:435-445 American College of Cardiology Foundation 15
Algorithm for Risk Assessment of Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. Multimodality imaging role in planning and guiding TAVR. A, Multiplanar reformatted CT images of a patient with a small elliptical aortic annulus requiring a 20-mm Sapien 3 valve, highlights the importance of patient-specific sizing and the measurement of the left main height. Marcelo F. Di Carli et al. Circulation. 2016;133:2640-2661 Copyright American Heart Association, Inc. All rights reserved. 16
Take home points ECHO--Primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function MRI High spatial resolution and complex cardiomyopathies SPECT reliable stress test PET Better images and less radiation CCTA Good for subclinical disease and with FFR capabilities Meaningful use criteria more to come with CMS in 2018 17